SEPSIS—July 28, 2016

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Disclosure Statement

The following staff and speakers have disclosed that neither they nor spouses/partners have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity:

Donna Martin, DNP, RN, CMSRN, CDE

Antoinette Pretto-Sparkuhl RN, BSN, MBA, MHA

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Managing Patient Outcomes:

The Battle Against Sepsis

Reviewer Perspective

Donna Martin, DNP, RN, CMSRN, CD

Disease-Specific Care Certification ReviewerJoint Commission

Customer Perspective

Antoinette Pretto-Sparkuhl RN, BSN, MBA, MHA

Senior Director Clinical ExcellenceFar West Division | HCA

July 28, 2016

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Reviewer Perspective

Donna Martin, DNP, RN, CMSRN, CDE

Disease-Specific Care Certification Reviewer

The Joint Commission

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Sepsis Statistics

In the US, more than 250,000 sepsis patients die annually

Sepsis is the most expensive disease to treat in the hospital, costing approximately $20 Billion annually

Sepsis mortality can be reduced with early detection & rapid initiation of treatment

Source: Sepsis Alliance 2016Source: Elixhauser et al., Septicemia in U.S. Hospitals, 2009. HCUP Statistical Brief #122. October, 2011. Agency for Healthcare Research and Quality, Rockville, MD.

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Who is eligible for certification?

Joint Commission accredited organizationProgram has served a minimum of 10

patientsUse of standardized clinical care delivery

based on evidence-based care and clinical practice guidelines

Data collection and performance measurement data

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Sepsis Certification Model

Quality & Safety of Care for Patients

ProcessClinical Practice

Guidelines

StructureConsensus-based national standards

OutcomePerformance Measures

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Structure: Certification Standards

Certification Participation RequirementsProgram Management Delivering or Facilitating Clinical CareSupporting Self-ManagementClinical Information ManagementPerformance Management

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Performance Measurement :

(DSPM) Chapter

Implements an organized, comprehensive approach to performance improvement

Collects and analyzes PI data Uses this data and information to improve or

validate care, treatment, or services providedAnalyzes the patient transfer process

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Process: Clinical Practice

Guidelines

Clinical care based on guidelines/evidence-based practice

Review validates:– Implementation of CPGs– Rationale for selection/modification– Monitoring & improving adherence

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Process: Clinical Practice

Guidelines

On-line resource: National Guideline Clearinghouse at www.guideline.gov

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

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Outcome: Performance Measurement

Criteria

Four process or outcome measures to monitor on an ongoing basis

At least two of the measures must be clinicalUp to two measures can be non-clinical:

administrative, utilization, financial, patient satisfaction, etc.

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Performance Measurement:

Process

Define measures at time of application through use of Certification Measure Information Process

Share 4 months worth of trended data at initial onsite visit

Monitor data monthlyShare 12 months worth of trended data one

year after achieving certification

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What Makes a Good

Performance Measure?

Results can be used for improvementRelates to current medical evidenceDefined specificationsData collection is consistent and logical

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Performance Measure Ideas

Appropriate fluid bolus (if BP < 90 systolic or lactic acid >4 mmol/L)

Antibiotic timing (within 3 hours of identification of severe sepsis or septic shock)

Repeat lactic acid level (within 6 hours if severe sepsis or initial level >2mmol/L)

Overall bundle compliance Order set utilization Sepsis education (documentation within 24 hours,

ongoing, and/or at discharge) Co-morbidity education documentation

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Performance Measure Ideas Advanced directives Progressive mobility / Early ambulation ID rounds documented Order set utilization Initial Screening accuracy / Sepsis screen

documentation is accurate Vent hours Decrease time to CVP goal Decrease time to SCVO2 goal Increased Sepsis alerts / Sepsis RRT Antimicrobial stewardship

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Challenges of Certification

Consistent implementation of Clinical Practice Guidelines

Involvement of all physicians

Data collection on performance measures

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Best Practices for a Successful

Review

Follow the Review Process Guide (RPG) for an sample of the 1 Day Agenda. It will provide examples such as what occurs during the opening conference and times.

Understand that the agenda is used as a guide, dependent on staff and patient availability adjustments will be made

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Best Practices for a Successful

ReviewAssure you have all documents readyWhen asked for a policy, procedure,

guideline, be timelyAssure staff and providers in units are

prepared to discuss delivery of care and PI activities

If you use EMR, have someone who can navigate the record and have a mobile computer charged and ready to use

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Why Get Certified?

Structure clinical programs of excellence Improve processes of careToot your horn to consumersEnhance your bottom line

– Attract more patientsCulture change: communication, loyalty,

teamwork

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Customer Perspective

Antoinette Pretto-Sparkuhl RN, BSN,

MBA, MHA

Senior Director Clinical ExcellenceFar West Division | HCA

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Antoinette Pretto-Sparkuhl RN, BSN, MBA, MHA

Senior Director Clinical ExcellenceFar West Division | HCA

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Overview of Health System

Hospital Corporation of America

HCA Fact Sheet: http://hcahealthcare.com/util/documents/HCA-presskit-fact-sheet.pdf

HCA Facts

• Founded in 1968

• 168 hospitals

• 116 free-standing surgery

centers

• 20 states and the U.K.

• 233,000

employees/79,000 nurses

• Approx. 5% of all U.S.

hospital services happen

at an HCA facility

• 106 Hospitals included in

the Joint Commissions

list of Top Performers on

Key Quality Measures

“Above all else, we are committed to the care and improvement of human life. In recognition of this commitment, we strive to

deliver high-quality, cost effective healthcare in the communities we serve.”

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The Pursuit to Sepsis Certification

Far West Division Sepsis is a key clinical initiative for HCA including FWD-

commitment to certification important for program success

Far West Division consists of 8 Hospitals in 3 markets:• Las Vegas Market:

• Sunrise Hospital and Medical Center (9/24/15)• MountainView Hospital and Medical Center (9/25/15)• Southern Hills Hospital and Medical Center (1/12/16)

• Northern California Market:• Good Samaritan Hospital (9/25/15)• Regional Medical Center (9/24/15)

• Southern California Market:• West Hills Hospital and Medical Center (4/22/16)• Riverside Community Hospital (1/5/16)• Los Robles Regional Medical Center-(pending)

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Required Elements for Success

FWD/Facility Leadership support Sepsis Program essentials:

• Sepsis Coordinator at facility• Multidisciplinary Sepsis Committee that meets

monthly• Physician Champion who also serves as the Co-

Chair for Sepsis Committee• Code Sepsis Process (Policy and Procedure)• Tracking of key metrics• Disease specific order sets• Program follows current evidence (CPG)• Intensivist program not mandatory, but preferred

Who is managing these patients in ICU?

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Certification Strategy

Development of a timeline:• Timeline

• Plan to have all FWD facilities apply by end of November 2015

• Plan to have all certified by mid-2016 • Currently 7/8 facilities are certified

Development of a strategy:• Toolkit

• Standards Analysis Gap with selection of PI measures

• Application Preparation• Review of Certification Review Process Guide

Disease Specific Care• Perform tracers-baseline data

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Certification Focus Areas

Nursing Care Plan-Clinical and patient goals Patient/Family Education with sepsis focus Sepsis Brochures-multiple languages to meet populations

needs Processes for bundle/RRT/Code Sepsis/Shock Alert etc. Mobility of patients in ICU-following physician orders Handoff from one shift to another with sepsis focus Documentation of Multi-disciplinary rounds in EHR IRR-Inter-rater reliability of data EMS collaboration e.g. education? Pre-hosp. notification? Implementation of bundle-evaluate

timeframes/appropriateness Role of Intensivist at facility Code Sepsis processes-Inpatient and ED

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Certification Focus Areas

Community Outreach-Education Care transitions-moving from one level of care to

another-how do you handle? Staff education-include ancillary staff Patient Satisfaction-How do you measure and what

do you do with data? Multi-disciplinary Education-documented in EHR Discharge Planning process

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Challenges

Sepsis population is much broader patient population than other disease specific programs making it more challenging to be compliant with standards

Sepsis certification is not just being compliant with bundle-that is the minimum. Program functions need to go above and beyond e.g.-Patient/Family Education, EMS collaboration, Physician engagement

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Challenges

Focus of program should not only be on the sickest patients, severe sepsis and septic shock but also on the patient with simple sepsis

Increased visibility of sepsis as urgent “Code” just as urgent as STEMI and Stroke

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Application Process

Brian R. Johnson, Ph.D.

Associate Director The Joint Commission

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Certification Logistics

Pre• Gap analysis to standards and guidelines; resolution of any gaps• Apply 4-6 months before desired review date• Data Collection

Visit• 30 days advance notification of date• One reviewer

Post• Data collection and submission• Intracycle conference call 12 months after visit• Apply for recertification

Visit• Recertification visit occurs 2 years after initial visit• To be scheduled within 90 day window around anniversary date• 7 days advance notice of date

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Questions Regarding Our Standards

Standards Interpretations Group (SIG)

The best source for all inquiries regarding the Standards can be forwarded to SIG.

They can be reached at 630-792-5900. Alternatively, questions can be posted via email by going to https://www.jointcommission.org/standards_information/jcfaq.aspx

Please use the “complete the standards online question form” to submit your questions.

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Application Process

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Application Process

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Application Process

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Application Process

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Application Process

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Application Process

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Contact Information

Brian R. Johnson, Ph.D. Associate Director, Business Development The Joint Commission Bjohnson@jointcommission.org630-792-5144

Antoinette Pretto-Sparkuhl RN, BSN, MBA, MHASenior Director Clinical ExcellenceFar West Division | HCA Antoinette.Pretto-Sparkuhl@hcahealthcare.com

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Q&A

Submit your questions into our attendee control panel. We will answer as many questions as we can.

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The Joint Commission Disclaimer

These slides are current as of 7/28/2016. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.